Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well-Being: The STRIDE Study

BACKGROUND/OBJECTIVES

In the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability.

DESIGN

Pragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries.

SETTING

A total of 86 primary care practices within 10 U.S. healthcare systems.

PARTICIPANTS

A random subsample of 743 persons aged 75 and older.

MEASUREMENTS

The well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument.

RESULTS

Participants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference.

CONCLUSIONS

STRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.

D-CARE: The Dementia Care Study: Design of a Pragmatic Trial of the Effectiveness and Cost Effectiveness of Health System-Based Versus Community-Based Dementia Care Versus Usual Dementia Care

BACKGROUND/OBJECTIVES

Although several approaches have been developed to provide comprehensive care for persons living with dementia (PWD) and their family or friend caregivers, the relative effectiveness and cost effectiveness of community-based dementia care (CBDC) versus health system-based dementia care (CBDC) and the effectiveness of both approaches compared with usual care (UC) are unknown.

DESIGN

Pragmatic randomized three-arm superiority trial. The unit of randomization is the PWD/caregiver dyad.

SETTING

Four clinical trial sites (CTSs) based in academic and clinical health systems.

PARTICIPANTS

A total of 2,150 English- or Spanish-speaking PWD who are not receiving hospice or residing in a nursing home and their caregivers.

INTERVENTIONS

Eighteen months of (1) HSDC provided by a nurse practitioner or physician's assistant dementia care specialist who works within the health system, or (2) CBDC provided by a social worker or nurse care consultant who works at a community-based organization, or (3) UC with as needed referral to the Alzheimer's Association Helpline.

MEASUREMENTS

Primary outcomes: PWD behavioral symptoms and caregiver distress as measured by the Neuropsychiatric Inventory Questionnaire (NPI-Q) Severity and Modified Caregiver Strain Index scales.

SECONDARY OUTCOMES

NPI-Q Distress, caregiver unmet needs and confidence, and caregiver depressive symptoms. Tertiary outcomes: PWD long-term nursing home placement rates, caregiver-reported PWD functional status, cognition, goal attainment, "time spent at home," Dementia Burden Scale-Caregiver, a composite measure of clinical benefit, Quality of Life of persons with dementia, Positive Aspects of Caregiving, and cost effectiveness using intervention costs and Medicare claims.

RESULTS

The results will be reported in the spring of 2024.

CONCLUSION

D-CARE will address whether emphasis on clinical support and tighter integration with other medical services has greater benefit than emphasis on social support that is tied more closely to community resources. It will also assess the effectiveness of both interventions compared with UC and will evaluate the cost effectiveness of each intervention.

Sex Hormones and Novel Corona Virus Infectious Disease (COVID-19)

Given the rapid spread of the coronavirus disease 2019 (COVID-19) pandemic and its overwhelming effect on health care systems and the global economy, innovative therapeutic strategies are urgently needed. The proposed primary culprit of COVID-19 is the intense inflammatory response-an augmented immune response and cytokine storm-severely damaging the lung tissue and rendering some patients' conditions severe enough to require assisted ventilation. Sex differences in the response to inflammation have been documented and can be attributed, at least in part, to sex steroid hormones. Moreover, age-associated decreases in sex steroid hormones, namely, estrogen and testosterone, may mediate proinflammatory increases in older adults that could increase their risk of COVID-19 adverse outcomes. Sex hormones can mitigate the inflammation response and might provide promising therapeutic potential for patients with COVID-19. In this article, we explore the possible anti-inflammatory effects of estrogen and testosterone and the anabolic effect of testosterone, with particular attention to the potential therapeutic role of hormone replacement therapy in older men and women with COVID-19.

A Randomized Trial of a Multifactorial Strategy to Prevent Serious Fall Injuries

BACKGROUND

Injuries from falls are major contributors to complications and death in older adults. Despite evidence from efficacy trials that many falls can be prevented, rates of falls resulting in injury have not declined.

METHODS

We conducted a pragmatic, cluster-randomized trial to evaluate the effectiveness of a multifactorial intervention that included risk assessment and individualized plans, administered by specially trained nurses, to prevent fall injuries. A total of 86 primary care practices across 10 health care systems were randomly assigned to the intervention or to enhanced usual care (the control) (43 practices each). The participants were community-dwelling adults, 70 years of age or older, who were at increased risk for fall injuries. The primary outcome, assessed in a time-to-event analysis, was the first serious fall injury, adjudicated with the use of participant report, electronic health records, and claims data. We hypothesized that the event rate would be lower by 20% in the intervention group than in the control group.

RESULTS

The demographic and baseline characteristics of the participants were similar in the intervention group (2802 participants) and the control group (2649 participants); the mean age was 80 years, and 62.0% of the participants were women. The rate of a first adjudicated serious fall injury did not differ significantly between the groups, as assessed in a time-to-first-event analysis (events per 100 person-years of follow-up, 4.9 in the intervention group and 5.3 in the control group; hazard ratio, 0.92; 95% confidence interval [CI], 0.80 to 1.06; P = 0.25). The rate of a first participant-reported fall injury was 25.6 events per 100 person-years of follow-up in the intervention group and 28.6 events per 100 person-years of follow-up in the control group (hazard ratio, 0.90; 95% CI, 0.83 to 0.99; P = 0.004). The rates of hospitalization or death were similar in the two groups.

CONCLUSIONS

A multifactorial intervention, administered by nurses, did not result in a significantly lower rate of a first adjudicated serious fall injury than enhanced usual care. (Funded by the Patient-Centered Outcomes Research Institute and others; STRIDE ClinicalTrials.gov number, NCT02475850.).

A Phase I Randomized Clinical Trial of Evidence-Based, Pragmatic Interventions to Improve Functional Recovery After Hospitalization in Geriatric Patients

BACKGROUND

Physical function declines during hospitalization in geriatric patients, increasing the risk of loss of independence. There is a need for evidence-based, pragmatic interventions to improve functional recovery of older adults following acute hospitalization. Here, we report the results of a Phase I randomized clinical trial designed to determine safety and effect size of protein supplementation, exercise, and testosterone interventions on 30-day post-discharge functional recovery and readmissions in geriatric patients.

METHODS

A total of 100 patients admitted to the University of Texas Medical Branch hospital for an acute medical illness were randomized to one of five intervention groups: isocaloric placebo, whey protein supplement, in-home rehabilitation + placebo, in-home rehabilitation + whey protein, or testosterone. Primary outcome measure was the change from baseline in short physical performance battery score at 1 and 4 weeks post-discharge. Secondary outcomes were changes in body composition, activities of daily living, and 30-day readmissions. Comparisons were made across study groups and between placebo and all active intervention groups.

RESULTS

Four weeks post-discharge, the short physical performance battery total score and balance score increased more in active intervention groups than placebo group (p < .05). There were no significant differences in change in body composition or activities of daily living across groups or between active intervention groups and placebo group. Readmission rates were highest in placebo (28%), followed by rehabilitation + placebo (15%), whey protein (12%), rehabilitation + whey protein (11%), and testosterone (5%). There was a trend for lower readmission rates in all active intervention groups (11%) versus placebo group (28%).

CONCLUSIONS

Findings from this Phase I clinical trial suggest that pragmatic, evidence-based interventions may accelerate recovery from acute hospitalization in geriatric patients. These data provide essential information to design larger randomized controlled trials to test the effectiveness of these interventions.

Effect of Aerobic Exercise Training and Essential Amino Acid Supplementation for 24 Weeks on Physical Function, Body Composition, and Muscle Metabolism in Healthy, Independent Older Adults: A Randomized Clinical Trial

BACKGROUND

Essential amino acids (EAA) and aerobic exercise (AE) acutely and independently stimulate skeletal muscle protein anabolism in older adults.

OBJECTIVE

In this Phase 1, double-blind, placebo-controlled, randomized clinical trial, we determined if chronic EAA supplementation, AE training, or a combination of the two interventions could improve muscle mass and function by stimulating muscle protein synthesis.

METHODS

We phone-screened 971, enrolled 109, and randomized 50 independent, low-active, nonfrail, and nondiabetic older adults (age 72 ± 1 years). We used a 2 × 2 factorial design. The interventions were: daily nutritional supplementation (15 g EAA or placebo) and physical activity (supervised AE training 3 days/week or monitored habitual activity) for 24 weeks. Muscle strength, physical function, body composition, and muscle protein synthesis were measured before and after the 24-week intervention.

RESULTS

Forty-five subjects completed the 24-week intervention. VO2peak and walking speed increased (p < .05) in both AE groups, irrespective of supplementation type, but muscle strength increased only in the EAA + AE group (p < .05). EAA supplementation acutely increased (p < .05) muscle protein synthesis from basal both before and after the intervention, with a larger increase in the EAA + AE group after the intervention. Total and regional lean body mass did not change significantly with any intervention.

CONCLUSIONS

In nonfrail, independent, healthy older adults AE training increased walking speed and aerobic fitness, and, when combined with EAA supplementation, it also increased muscle strength and EAA-stimulated muscle protein synthesis. These increases occurred without improvements in muscle mass.

Effects of Amino Acid Supplementation on Liver Lipid Content: A Randomized, Double-Blinded, Placebo-Controlled Trial

Objectives

To test whether chronic ingestion of essential amino acids (EAAs) plus arginine lowers liver lipid content when compared with a placebo (non-essential amino acids; NEAAs).

Methods

Older adults (50–75 y) with elevated fasting plasma triacylglycerol (TAG) concentrations were recruited into the study. After screening (week -2), all participants ingested placebo (NEAAs; alanine, aspartic acid, and serine) capsules twice daily (between meals) for two weeks and 3 T nuclear magnetic resonance spectroscopy scans were used to determine baseline (week 0) liver lipid percentage. Participants were then randomised to receive capsules containing 11 g of EAAs plus arginine (n = 10) or NEAAs (n = 9) twice daily for eight weeks, using a double-blinded design. Follow-up NMR spectroscopy scans were conducted at eight weeks after the onset of randomised supplementation (week 8) to determine the impact on liver lipids.

Results

Liver lipid percentage (mean ± standard deviation) was not significantly altered by randomised supplementation in either the EAAs plus arginine group (Pre: 9.08 ± 7.90%; Post: 8.94 ± 6.91%; P = 0.65) or the NEAAs group (Pre: 10.23 ± 7.20%; Post: 9.65 ± 7.70%; P = 0.18). Change in fasting plasma TAG during placebo run-in (Week 0 minus screening) was significantly negatively correlated with change in liver lipid content (week 8 minus week 0) for the EAAs plus arginine group (r = −0.722; P = 0.02), but not for the NEAAs group A (r = −0.479; P = 0.19).

Conclusions

Eight weeks of essential amino acids plus arginine ingestion did not significantly lower liver lipid content in older adults. However, ingestion of non-essential amino acids during the run-in period may have influenced the effect on liver fat of subsequent randomised amino acid supplementation, suggesting further investigation is warranted.

Funding Sources

The study was sponsored by NIH/NIA (award to EB), and the Roy and Christine Sturgis Charitable Trust (award to NMH). Screenings and study visits were undertaken within the ITS-Clinical Research Center at UTMB, funded by NIH/NCRR, and within the UAMS Donald W. Reynolds Institute on Aging at UAMS, funded by NIH/NIA. NMH and EB were also funded by the Arkansas Biosciences Institute, the major research component of the Arkansas Tobacco Settlement Proceeds Act of 2000.

Resistance exercise training promotes fiber type-specific myonuclear adaptations in older adults

Aging induces physiological decline in human skeletal muscle function and morphology, including type II fiber atrophy and an increase in type I fiber frequency. Resistance exercise training (RET) is an effective strategy to overcome muscle mass loss and improve strength, with a stronger effect on type II fibers. In the present study, we sought to determine the effect of a 12-wk progressive RET program on the fiber type-specific skeletal muscle hypertrophic response in older adults. Nineteen subjects [10 men and 9 women (71.1 ± 4.3 yr)] were studied before and after the 12-wk program. Immunohistochemical analysis was used to quantify myosin heavy chain (MyHC) isoform expression, cross-sectional area (CSA), satellite cell abundance, myonuclear content, and lipid droplet density. RET induced an increase in MyHC type II fiber frequency and a concomitant decrease in MyHC type I fiber frequency. Mean CSA increased significantly only in MyHC type II fibers (+23.3%, P < 0.05), but myonuclear content increased only in MyHC type I fibers (P < 0.05), with no change in MyHC type II fibers. Satellite cell content increased ~40% in both fiber types (P > 0.05). RET induced adaptations to the capillary supply to satellite cells, with the distance between satellite cells and the nearest capillary increasing in type I fibers and decreasing in type II fibers. Both fiber types showed similar decrements in intramuscular lipid density with training (P < 0.05). Our data provide intriguing evidence for a fiber type-specific response to RET in older adults and suggest flexibility in the myonuclear domain of type II fibers during a hypertrophic stimulus.NEW & NOTEWORTHY In older adults, progressive resistance exercise training (RET) increased skeletal muscle fiber volume and cross-sectional area independently of myonuclear accretion, leading to an expansion of the myonuclear domain. Fiber type-specific analyses illuminated differential adaptation; type II fibers underwent hypertrophy and exhibited myonuclear domain plasticity, whereas myonuclear accretion occurred in type I fibers in the absence of a robust hypertrophic response. RET also augmented satellite cell-capillary interaction and reduced intramyocellular lipid density to improve muscle quality.

AGS and NIA Bench-to Bedside Conference Summary: Osteoporosis and Soft Tissue (Muscle and Fat) Disorders

This report summarizes the presentations and recommendations of the eleventh annual American Geriatrics Society and National Institute on Aging research conference, "Osteoporosis and Soft Tissue (Muscle/Fat) Disorders," on March 11-12, 2019, in Bethesda, Maryland. Falls, fractures, and sarcopenia have a major impact on health in older adults, and they are interconnected by known risk factors. The link between osteoporosis, which is common in older adults, and the risk of falls is well known. Sarcopenia, the age-related decline in skeletal muscle mass and function, is also associated with an increased risk of falls and fractures because it reduces strength and leads to functional limitations. In addition to increasing the risk of falls, sarcopenia and osteoporosis can lead to frailty, reduced quality of life, morbidity, and mortality. The conference highlighted the impact of bone and soft tissue disorders on quality of life, morbidity, and mortality in older adults. Presenters described factors that contribute to these disorders; health disparities experienced by various subpopulations; and promising biological, pharmacologic, and behavioral interventions to prevent or treat these disorders. The workshop identified many research gaps and questions along with research recommendations that have the potential to enhance the prospect of healthy aging and improved quality of life for older adults. J Am Geriatr Soc 68:31-38, 2019.

EFFECTS OF RESISTANCE EXERCISE TRAINING ON ENDOTHELIAL FUNCTION AND MUSCLE PERFUSION IN OLDER ADULTS WITH DIABETES

BACKGROUND: Sarcopenia contributes to frailty, disability, and dependence in older adults, and is accelerated by Type 2 Diabetes Mellitus (T2DM). In addition to its direct role in increasing muscle mass, progressive resistance exercise training (PRET) may also reduce sarcopenia by improving endothelial function and muscle perfusion. METHODS: Fifteen older adults with uncomplicated and well-controlled T2DM participated in a PRET program 3 times weekly for 3 months. Prior to and immediately following the intervention, flow-mediated dilation testing was performed to assess large vessel endothelial function via ultrasound and muscle perfusion via near-infrared spectroscopy (NIRS). RESULTS: Preliminary ultrasound data from 9 subjects show a significant increase (5.21% to 8.73%, p=0.0448) in percent flow mediated dilation (%FMD), suggesting a modest improvement in endothelial function after 3 months’ PRET. Preliminary NIRS data from 7 subjects showed no significant changes in oxygen saturation or reperfusion rates as a result of the intervention. CONCLUSION: Our preliminary data indicate that, in older adults with T2DM, 3 months’ PRET is associated with modestly improved endothelial function in large vessels (as demonstrated by a significant increase in %FMD), but does not appear to be associated with improvements in muscle perfusion

DETERMINING THE PREVALENCE OF SARCOPENIA IN AN INPATIENT GERIATRIC POPULATION USING EWGSOP2 OR FNIH DEFINITIONS

Sarcopenia has been recognized as a progressive and generalized skeletal muscle disorder leading to loss of strength, muscle mass, and function. It is associated with an increased likelihood of adverse outcomes like falls, fractures, physical disability, and mortality. International consensus groups continue providing new definitions and clinical cut-off points despite over a decade of work in this area. Thus, the purpose of this research was to determine the prevalence of sarcopenia using two of the most current operational definitions (Foundation of NIH Sarcopenia Project (FNIH) and the European Working Group on Sarcopenia in Older Persons 2 (EWGSOP2)). Our cohort of acutely hospitalized older adults was formed from combining data from two randomized controlled trials and one cross-sectional observational study. Testing during hospitalization included measures of: demographics, body composition (DEXA), physical function tests, psychological wellbeing and independence questionnaires, and chart review. These were used to analyze the cohort according to three main groupings of low physical performance, low muscle strength, and low lean mass. We compared multiple tests and cutoffs for each of the three groupings under the FNIH and EWGSOP2 definitions, which varied 3% for low lean mass up to 48% for tests of low physical performance. After examining the efficacy of each cutoff, we evaluated the differences between FNIH and EWGSOP2. In our cohort, the prevalence of sarcopenia was 15.79% by EWGSOP2 and 13.59% by FNIH. The groupings within FNIH and EWGSOP2 were found to be near identical across almost all measures despite the definitions’ discrepancies in cutoff points.

POST DISCHARGE WALKING ACTIVITY AND 30-DAY READMISSION IN OLDER ADULTS

The Centers for Medicare and Medicaid Services has determined high rates of unplanned 30-day readmission to be an indicator of substandard care. More research is needed to identify strong, objective markers of readmission risk. The purpose of this analysis was to investigate the utility of average steps per day as a biomarker in determining the 30-day readmission risk of recently discharged older adults. 133 men and women, aged 65 and older, who were capable of walking on their own, recently hospitalized with an acute illness, and discharged to home were given a StepWatch Activity Monitor and monitored for up to 30 days following discharge. Average steps per day and clinical characteristics were assessed and compared with 30-day readmission. 20 of 133 participants were readmitted within 30 days. Those who were readmitted took significantly fewer steps per day overall: 4412 vs. 5948, p=0.027, and had significantly longer stays in the hospital: 4.50 vs. 2.90 days, p=0.002. Survival analysis of our sample, grouped by tertile of mean daily steps, while not statistically significant, p=0.093, demonstrated a trend toward greater probability of readmission over the 30 days post discharge for those who were in the lowest tertile. Walking activity appears to be a moderate predictor of readmission risk. A more extensive study must be conducted to better understand the relationship of walking activity after discharge and readmission.

Developing a screening tool for sarcopenia in hospitalized geriatric patients: Estimation of appendicular skeletal muscle mass using bioelectrical impedance

BACKGROUND & AIMS

Sarcopenia is now a billable ICD-10 geriatric condition characterized by low appendicular skeletal muscle mass (ASMM) and low function. There is an increasing need for portable, provider-friendly, cost-effective methods for estimating ASMM. The overall goal of this project was to create and validate a regression model for obtaining ASMM from Bioelectrical Impedance Analysis (BIA) measurements using Dual-energy X-ray Absorptiometry (DXA) as the reference.

METHODS

Geriatric patients (≥65 years of age) were enrolled during an acute hospitalization. Body composition measurements were obtained through DXA and BIA devices. The ASMM prediction model was derived using stepwise multiple regression modeling. The model was 10 fold validated and tested as a screening tool (sensitivity, specificity, positive and negative predictive values) using the Foundation for the NIH Sarcopenia Project (FNIH) definition.

RESULTS

The following variables were selected by stepwise regression modeling: sex, body mass index, max grip strength, and fat mass derived by BIA. The model was internally validated with 10 fold cross validation. Using the FNIH definition, the model was found to have a sensitivity of 80%, a specificity of 91%, a positive predictive value of 73% and a negative predictive value of 93%.

CONCLUSIONS

We have developed a screening tool that can be easily used in geriatric patients to screen for sarcopenia. Once validated with a larger sample, the developed prediction model can be used to estimate ASMM using provider-friendly measurements and can be easily implemented as a sensitive screening tool for identifying patients at risk for sarcopenia. Those identified at risk would undergo further functional testing for diagnosis and treatment of sarcopenia.

Low skeletal muscle capillarization limits muscle adaptation to resistance exercise training in older adults

OBJECTIVES

Adequate muscle perfusion supports the transport of nutrients, oxygen and hormones into muscle fibers. Aging is associated with a substantial decrease in skeletal muscle capillarization, fiber size and oxidative capacity, which may be improved with regular physical activity. The aim of this study was to investigate the relationship between muscle capillarization and indices of muscle hypertrophy (i.e. lean mass; fiber cross sectional area (CSA)) in older adults before and after 12 weeks of progressive resistance exercise training (RET).

DESIGN

Interventional study SETTING AND PARTICIPANTS: 19 subjects (10 male and 9 female; 71.1 ± 4.3 years; 27.6 ± 3.2 BMI) were enrolled in the study and performed a whole body RET program for 12 weeks. Subjects where then retrospectively divided into a LOW or HIGH group, based on their pre-RET capillary-to-fiber perimeter exchange index (CFPE). Physical activity level, indices of capillarization (capillaries-to-fiber ratio, C:Fi; CFPE index and capillary-to-fiber interface, LC-PF index), muscle hypertrophy, muscle protein turnover and mitochondrial function were assessed before and after RET.

RESULTS

Basal capillarization (C:Fi; CFPE and LP-CF index) correlates with daily physical activity level (C:Fi, r = 0.57, p = 0.019; CFPE index, r = 0.55, p = 0.024; LC-PF index, r = 0.56, p = 0.022) and CFPE and LC-PF indices were also positively associated with oxidative capacity (respectively r = 0.45, p = 0.06; r = 0.67, p = 0.004). Following RET, subjects in the HIGH group underwent hypertrophy with significant improvements in muscle protein synthesis and muscle fiber CSA (p < 0.05). However, RET did not promote muscle hypertrophy in the LOW group, but RET significantly increased muscle capillary density (p < 0.05).

CONCLUSION/IMPLICATIONS

Muscle fiber capillarization before starting an exercise training program may be predictive of the muscle hypertrophic response to RET in older adults. Increases in muscle fiber size following RET appear to be blunted when muscle capillarization is low, suggesting that an adequate initial capillarization is critical to achieve a meaningful degree of muscle adaptation to RET.

Effect of essential amino acid supplementation and aerobic exercise on insulin sensitivity in healthy older adults: A randomized clinical trial

BACKGROUND & AIMS

The combination of prolonged essential amino acid (EAA) supplementation and aerobic exercise training (Ex) improves muscle protein metabolism, strength and function in healthy older adults. However, excess EAA intake may worsen insulin sensitivity. Here we report the effects of EAA supplementation (EAA, n = 11), placebo (PLA, n = 10), aerobic exercise with placebo (Ex + PLA, n = 11) or Ex with EAA supplementation (Ex + EAA, n = 10) for 22 weeks on insulin sensitivity in non-diabetic older adults.

METHODS

A 2 × 2 design with block randomization and double blinding for supplement or placebo was used. Subjects ingested EAA (15 g) or placebo daily. Exercising subjects participated in supervised progressive vigorous treadmill walking 3 times weekly. Measures of insulin sensitivity by oral glucose tolerance testing were collected at baseline and 22 weeks. Dietary intakes of protein and specific amino acids were determined in a subset of subjects.

RESULTS

Overall, exercise improved insulin sensitivity, while EAA supplementation had no effect. In the dietary subset, post-intervention insulin sensitivity did not correlate significantly with the total intake of EAA, anti-angiogenic amino acids (cysteine, methionine), or branched-chain amino acids (isoleucine, leucine, valine).

CONCLUSIONS

Overall, we conclude that in healthy older adults with moderate protein intake, EAA supplementation is metabolically safe as it does not decrease insulin sensitivity regardless of its combination with aerobic exercise. Thus, daily protein intake should be controlled for when modeling insulin sensitivity. Future studies should explore the role of increased blood flow as a potential explanatory factor for the observed interaction between aerobic exercise and supplementation.

CLINICAL TRIAL REGISTRATION NUMBER

NCT00872911.

Whey Protein Hydrolysate Increases Amino Acid Uptake, mTORC1 Signaling, and Protein Synthesis in Skeletal Muscle of Healthy Young Men in a Randomized Crossover Trial

BACKGROUND

Muscle protein synthesis (MPS) can be stimulated by ingestion of protein sources, such as whey, casein, or soy. Protein supplementation can enhance muscle protein synthesis after exercise and may preserve skeletal muscle mass and function in aging adults. Therefore, identifying protein sources with higher anabolic potency is of high significance.

OBJECTIVE

The aim of this study was to determine the anabolic potency and efficacy of a novel whey protein hydrolysate mixture (WPH) on mechanistic target of rapamycin complex 1 (mTORC1) signaling and skeletal MPS in healthy young subjects.

METHODS

Ten young men (aged 28.7 ± 3.6 y, 25.2 ± 2.9 kg/m2 body mass index [BMI]) were recruited into a double-blind two-way crossover trial. Subjects were randomized to receive either 0.08 g/kg of body weight (BW) of WPH or an intact whey protein (WHEY) mixture during stable isotope infusion experiments. Fractional synthetic rate, leucine and phenylalanine kinetics, and markers of amino acid sensing were assessed as primary outcomes before and 1-3 h after protein ingestion using a repeated measures mixed model.

RESULTS

Blood leucine concentration, delivery of leucine to muscle, transport of leucine from blood into muscle and intracellular muscle leucine concentration significantly increased to a similar extent 1 h after ingestion of both mixtures (P < 0.05). Phosphorylation of S6K1 (i.e. a marker of mTORC1 activation) increased equally by ∼20% 1-h postingestion (P < 0.05). Ingestion of WPH and WHEY increased mixed MPS similarly in both groups by ∼43% (P < 0.05); however, phenylalanine utilization for synthesis increased in both treatments 1-h postingestion but remained elevated 3-h postingestion only in the WPH group (P < 0.05).

CONCLUSIONS

We conclude that a small dose of WPH effectively increases leucine transport into muscle, activating mTORC1 and stimulating MPS in young men. WPH anabolic potency and efficacy for promoting overall muscle protein anabolism is similar to WHEY, an intact protein source. This trial was registered at clinicaltrials.gov as NCT03313830.

Comparison of Malnutrition Screening Tools for Use in Hospitalized Older Adults (OR36-02-19)

Objectives

Malnutrition is a common problem in geriatric patients that often goes unrecognized. Undernutrition is a primary health concern for older adults due to associations with increased mortality, complications, and length of hospital stay. Yet, there is no consensus on which malnutrition screening tool should be used for hospitalized older adults. Therefore, the objective of this study was to determine which screening tool is best to rapidly detect malnutrition in hospitalized older adults so that patient outcomes may be improved.

Methods

Older adult patients (n = 211; ≥65 yrs old) were enrolled during acute hospitalization. Testing occurring within 72 hours of admission and included the following screening tools included: Malnutrition Screening Tool (MST), Mini Nutritional Assessment Short Form (MNA-SF), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screening 2002 (NRS-2002), and Geriatric Nutritional Risk Index (GNRI). These screening tools were compared to a malnutrition diagnostic tool, the Subjective Global Assessment (SGA).

Results

According to SGA, 49% of patients were at risk of being malnourished. The other screening tools indicated a wide range of malnutrition prevalence, from 18% (MST) to 76% (MNA-SF). MST (93%) and MUST (92%) were highest in sensitivity. NRS-2002 had moderately good sensitivity (71%). MNA-SF and GNRI had poor sensitivity, eliminating them as good screening tools for hospitalized elderly patients. Of the remaining tools, NRS-2002 had the highest specificity (77%). MST and MUST had poor specificity (31%, 39%, respectively), eliminating them as good screening tools for hospitalized elderly patients. The remaining screening tool, NRS-2002, had moderately good positive and negative predictive values (76%, 72%, respectively). It also had the highest kappa (0.479). Overall, NRS-2002 had the best agreement to SGA and showed moderately good sensitivity, specificity and predictive values.

Conclusions

Our data suggests NRS-2002 is the best malnutrition screening tool for rapid detection of malnutrition in elderly hospitalized patients, when compared to the diagnostic tool, SGA. Future research is needed to determine which screening tool is most effective for use in different settings. Additional research can assist in standardizing malnutrition criteria and care processes.

Funding Sources

National Dairy Council, National Institutes of Health-National Center for Advancing Translational Sciences, and UTMB Claude D. Pepper OAIC.

Supporting Tables, Images and/or Graphs

A Randomized Controlled Pilot Trial of Interventions to Improve Functional Recovery After Hospitalization in Older Adults: Feasibility and Adherence

Background

Hospitalization is a major risk factor for functional decline, disability, loss of independence, and mortality in older adults. Evidence-based interventions to improve functional recovery from hospitalization are difficult to evaluate and implement in geriatric patients. The goal of this pilot study was to test the feasibility of recruiting geriatric inpatients and implementing pragmatic interventions to improve physical function following hospitalization.

Methods

Enrolled subjects were randomized to one of five 30-day posthospitalization interventions: isocaloric placebo (P), whey protein supplement (W), in-home rehabilitation+placebo (R+P), rehabilitation+whey protein (R+W), or testosterone (T). Data were collected from a single-site university hospital to determine: (i) institution-based feasibility (nonmodifiable factors including number of patients screened, eligible, contacted) and (ii) patient-based feasibility (modifiable factors including number of patients refusing, enrolled, randomized, intervention adherence, and withdrawal).

Results

From January 2014 to July 2016, 4,533 patients were chart screened; 594 (13.1%) were eligible to participate; 384 eligible subjects were contacted; 113 were enrolled; and 100 were randomized. Supplement adherence was 75% and was not different by age, education, level of independence, depression, supplement type, or dual intervention, but was significantly higher in subjects who completed the intervention (p < .01). Rehabilitation session adherence was 77% and did not vary significantly by age, education, level of independence, depression, or supplement type, but was significantly higher for sessions directly supervised (p < .01). Adherence was 100% in the testosterone arm with 94.7% of injections given within 24 hours of discharge.

Conclusions

Findings from this clinical trial indicate that posthospitalization interventions in geriatric patients are feasible at both the institution and patient level.

Moderate-intensity aerobic exercise improves skeletal muscle quality in older adults

Sarcopenia, age-associated involuntary loss of muscle and strength, can progress to clinically relevant functional decline. Resistance exercise attenuates muscle and strength loss but may not be feasible for some older adults. Aerobic exercise training (AET) improves cardiopulmonary health; however, effects on protein turnover, muscle mass, and strength are less clear. We aimed to determine whether AET improves basal myofibrillar protein synthesis (MPS) and capillarization, promoting hypertrophy and strength. We hypothesized that AET improves strength with increased MPS and capillarization. Older adults were randomized to non-exercise (NON; n = 11, 71.4 ± 4.18 years) or exercise (EX; n = 12, 73.7 ± 4.05 years). EX completed 24 weeks of AET (walking 3×/week, 45 minutes, 70% heart rate reserve); NON remained sedentary. A stable isotope tracer was infused. MPS and capillarization were analyzed from vastus lateralis muscle biopsies. Strength was measured via isokinetic dynamometry. Lean mass was determined with dual-energy X-ray absorptiometry. Basal MPS increased in EX (+50.7%, P = 0.01) along with capillary density (+66.4%, P = 0.03), peak oxygen consumption (+15.8%, P = 0.01), quadriceps strength (+15.1%, P = 0.01), and muscle quality (peak torque divided by leg lean mass, +15.5%, P = 0.01). Lean mass did not change (P > 0.05). AET increases muscle protein turnover and capillarization in older adults, improving muscle quality.

Functional Improvements Utilizing the Short Physical Performance Battery (SPPB) in the Elderly after Epidural Steroid Injections

PURPOSE OF REVIEW

The treatment of debilitating pain and loss of function secondary to lumbar stenosis is in high demand with the aging patient population. Options, including epidural steroid injections (ESIs) and medication therapy, are limited and it is unclear if they provide any functional improvements. In this prospective study, we evaluate functional outcomes in older adults with symptomatic lumbar stenosis treated with ESIs compared to those managed with medications by introducing the Short Physical Performance Battery (SPPB). Our study was IRB-approved and included 16 patients, 68 to 83 years old, with symptomatic back and radicular leg pain secondary to lumbar stenosis. Patients could elect to undergo a lumbar ESI (n = 11) or be treated via medication management (n = 5). Numeric pain score, SPPB score, and adverse events were measured and compared at baseline and a 1-month follow-up visit.

RECENT FINDINGS

Statistically significant improvements were observed from baseline compared to the 1-month follow-up for total SPPB score in the injection group. Similar improvements in the injection group were observed for pain scores and the SPPB subcomponents such as the 4-m walk test, chair stand time, and balance score. Comparatively, no statistically significant improvements were observed in the medication group. Lumbar ESIs improved objective physical capacity parameters and pain scores in elderly patients with symptomatic lumbar stenosis compared to medication management. In addition, the SPPB is an easy-to-use tool to measure changes in physical function in older adults and could easily be integrated into an outpatient pain clinic.

Tricyclic Antidepressant and/or γ-Aminobutyric Acid-Analog Use Is Associated With Fall Risk in Diabetic Peripheral Neuropathy

BACKGROUND/OBJECTIVES

Peripheral neuropathy is a common diabetes complication that can increase fall risk. Regarding fall risk, the impact of pain management using tricyclic antidepressants (TCAs) or γ-aminobutyric acid (GABA) analogs is unclear because these medications can also cause falls. This study investigates the impact of these drugs on fall and fracture risk in older diabetic peripheral neuropathy (DPN) patients.

DESIGN

Historical cohort study with 1-to-1 propensity matching of TCA/GABA-analog users and nonusers.

SETTING

Nationally representative 5% Medicare sample between the years 2008 and 2010.

PARTICIPANTS

After applying all selection criteria, 5,550 patients with prescription and 22,200 patients without prescription of TCAs/GABA-analogs were identified. Both patient groups were then stratified for fall history and matched based on propensity of receiving TCAs/GABA-analogs within each group.

MEASUREMENTS

Patients were followed until the first incidence of fall or the first incidence of fracture during the follow-up period (for up to 5 years).

RESULTS

After matching, users and nonusers were largely similar. After covariate adjustment, TCA/GABA-analog use was associated with a statistically significant increase in fall risk (adjusted hazard ratio [HR] = 1.11; 95% confidence interval [CI] = 1.03-1.20), but was not associated with fracture risk (adjusted HR = 1.09; 95% CI = 0.99-1.19) in the conventional analysis. Treating TCA/GABA-analog use as a time-dependent covariate resulted in statistically significant associations of TCA/GABA-analog use with both fall and fracture risk (HR = 1.26 [95% CI = 1.17-1.36]; and HR = 1.12 [95% CI = 1.02-1.24], respectively).

CONCLUSION

Among older patients with DPN, GABA-analogs or TCAs increase fall risk and possibly fracture risk. Use of these medications is therefore a potentially modifiable risk factor for falls and fractures in this population.